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The wily bureaucrat speaks his mind on the way out

YEARS AGO, when another governor stared down a year or two of demoralizing deficits, Nelson J. Sabatini came up with a way to help. It looked a lot like a scam.

The state would manufacture an increase in doctor fees. Federal authorities would then send the state more money because it gave Maryland about half of its expenses. If the doctor fees went up, the reimbursement went up. Maryland doctors agreed to send these extra millions to the state.

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In polite society, the plan was called "fool the feds."

Mr. Sabatini insisted - correctly - that Congress wanted the federal government to be duped. Democratic members engineered the higher payout to handle unfunded federal mandates. Something like that. Anyway, it worked. Mr. Sabatini still grins at the recollection.

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And he remains a hard-eyed practitioner of the bureaucratic arts. His recent public comments about velvet-glove hospital regulations are a case in point. With his resignation as Maryland's health secretary widely anticipated, Mr. Sabatini's comments qualify as an unusually constructive parting shot.

After Maryland General Hospital's laboratory failed to accurately complete tests for hepatitis and HIV, Mr. Sabatini testfied May 18 before a subcommittee of the U.S. House Government Reform Committee that was investigating the lapse.

He began by calling Maryland General's problems typical of hospitals throughout the nation. In 1999, he testified, the Institute of Medicine reported that as many as 100,000 patients a year died because of hospital errors. "That's about 2,000 a week, about 250 a day nationally. Every day," he said.

Given the Institute of Medicine report, he said, according to his prepared testimony, "I believe we can assume that Maryland General's problems are not unique in the industry." The problem, he said, is 30 years of self-regulation: "Federal and state regulatory agencies, which bear ultimate responsibility for ensuring quality health care, do not have the regulatory tools they need to provide any credible assurance of quality."

Quite an indictment. Mr. Sabatini says hospital regulation has been left to the American Hospital Association and the American College of Surgeons. Surely they would disagree, but they had company, in the secretary's view.

"The federal government and many state governments have abdicated, have turned over their authority to private-sector organizations, which have, in my view, uncomfortably close ties to the industry they survey," he testified. Mr. Sabatini included himself among the guilty.

The current regulatory investigations are "collegial in nature and leisurely in execution, and they focus almost entirely on process instead of outcome," he told the House panel.

By contrast, he said, "surveys we conduct at nursing homes and other long-term care facilities are periodic, unannounced, comprehensive and public." Much more rigorous, in other words.

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"The current system," he testified, "is frightening. It is cumbersome. It is bureaucratic. ... We are hindered by laws that prevent the discovery and slow the correction of problems. If 100,000 patients are dying in hospitals each year, it is occurring at least in part because of a system that for all intents and purposes allows the hospital industry to regulate itself."

Shortly after his testimony, Rep. Pete Stark, a California Democrat, asked him to return to Washington for a further, private discussion of the problems. What is needed, the secretary says, is a new regulatory system with the proverbial teeth.

"Why would we let hospitals admit more patients and do more damage when problems are discovered?" he wondered in an interview last week. He may get a chance to answer the question in a useful way. He's on his way out of office, but he could have another career ahead of him as a consultant. His experience, as they say, is bankable.

He's been an official at the University of Maryland Hospital, an official of the Social Security Administration and health secretary in two Maryland governments. Who has seen the problem at such a high elevation from both sides of the regulatory street?

If he can find a plan that doesn't introduce more bureaucratic entanglements, he might save some lives. Nice way to finish a public career.

C. Fraser Smith is news director for WYPR-FM. His column appears Sundays.


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